Tracheal intubation (TI) is a commonly performed life-saving procedure for critically ill children, but associated with frequent complications and adverse safety outcomes. With prior AHRQ and Pediatric Acute Lung Injury and Sepsis Investigator (PALISI) network support, we conducted a robust risk assessment using our multi-center pediatric TI safety registry: National Emergency Airway Registry for Children (NEAR4KIDS). We implemented a first generation TI quality improvement QI bundle including: 1) a TI risk factor checklist, 2) a bedside time-out immediately before TI, 3) a bedside time-out immediately after TI to debrief, and 4) quantitative debriefing among participating centers to share best practices. The evaluation of the clinical impact of this QI bundled intervention is ongoing with promising preliminary results (adverse TI associated event rate dropped from 19% to 16% across all NEAR4KIDS sites). However, with this QI implementation process, we have identified two precursor events: hypoxemia and multiple TI attempts, which need to be addressed to further improve TI safety. In this project, we will implement two easily adoptable interventions: apneic oxygenation (administration of oxygen throughout TI procedure via nasal cannula) and primary use of video laryngoscopes to reduce adverse TI associated events by minimizing hypoxemia and multiple attempts. This project will rigorously evaluate the clinical impact of this second generation QI intervention across a diverse spectrum of (large and small, academic and private) pediatric ICUs. Further, this project will identify and mitigate new QI practice uptake, adoption, implementation processes and variances at the site level. This approach includes standardized outcome measures using our NEAR4KIDS registry, measures of new QI practice uptake, a novel cumulative sum (CUSUM) analysis to track each site's performance prospectively, focus groups with sharp end multidisciplinary providers, and semi-structured interviews with site QI leaders. We will employ mixed- method quantitative and qualitative analyses to identify the key factors and barriers for this second generation bundled QI intervention adoption. Based on these analyses, we will further refine the QI implementation approach. The clinical impact of the implementation of apneic oxygenation and primary use of video laryngoscope will be measured prospectively by our NEAR4KIDS registry process of care measures, and most importantly by a meaningful absolute risk reduction in adverse TI associated events. Our NEAR4KIDS network has grown from 16 sites to 28 sites over last 2 years. At the completion of the this project, we have access to large implementation networks including PALISI and the American Heart Association life support training programs, who are poised to disseminate the findings beyond these 28 centers. Upon successful completion, we will understand the feasibility, barriers, and clinical impact of apneic oxygenation and video laryngoscopy on high-risk, but life-saving, TI procedural safety outcomes.